INTRODUCTION

Most people know that each person has two kidneys, their location, and that they are as essential to the maintenance of life as the other vital organs of the body are. Yet, fewer people are aware of the many functions the kidneys perform and the complications the kidneys may have. One complication of the kidneys is Nephrolithiasis, a urinary tract stone disease, which is a condition wherein stones referred to as calculi are present in the kidneys. Stones or these so called calculi can cause pain and blood in the urine but may also produce no symptoms. Urinary stones account for more than 320, 000 hospital admissions each year. The occurrence of urinary stones occurs predominantly in the third to fifth decades of life and affects men more than women. About half of the patients with a single renal stone have another episode within five years. (Smeltzer,S.C,et. al; Textbook of medical-surgical nursing(11th ed.), 2008 Lippincott William and Wilkins Publishing) In the United States, the lifetime prevalence of urinary tract stone disease is approximately 10%. The annual incidence of urinary tract stones in the industrialized world is estimated to be 0.2%. The likelihood that a white male will develop stone disease by age 70 years is 1 in 8. Stones of the upper urinary tract are more common in the United States than in the rest of the world. Roughly two million patients present on an outpatient basis with stone disease each year in the United States, which is a 40% increase from 1994. (http://kidney.niddk.nih.gov/kudisease/pubs/kustats/) The incidence of urinary tract stone disease in developed countries is similar to that in the United States. Stone disease is rare in only a few areas, such as Greenland and

the coastal areas of Japan. In developing countries, bladder calculi are more common than upper urinary tract calculi; the opposite is true in developed countries. These differences are believed to be diet-related. For Filipinos who are smokers, alcohol drinkers and are fond of eating salty and fatty foods, they are at risk for having such condition. Nephritis, nephritic syndrome, kidney stone and nephrosis has the number of 11,056 or 3.6% over 100,000 populations in the Philippines. (http://www.doh.gov.ph/kp/statistics/lading mortality as of 2008). When we had our exposure last August 3, 2010 at the gen. ward of St. Camillus Hospital, we were able to encounter a patient having Nephrolithiasis. The name of the disease itself sounded new and interesting to us so we thought having such patient with such kind of condition as the subject of our case study was a good idea. We asked permission from Mr. Lamaran to study his case. We got a yes and we are glad to share the facts we know about the disease.

Background of the Study The researchers chose to study this case since such condition is common to those who are fond of eating salty foods and we cannot deny the fact that we are amongst the thousands who are very much susceptible to have urinary tract complications. Further, studying this case would help us learn and understand thoroughly the detailed process of the disease, its prevention and treatment so as to somehow help the patient in restoring wellness by providing proper nursing interventions.

Significance of the Study As student nurses, having researches like this is very helpful to us, as well as to other health care providers, in expounding our knowledge regarding urinary tract stone diseases and rendering quality nursing care to patients having such kind of disease. Moreover, this could also be useful to health educators and students may they be in line with medicine or not since this could serve as guidelines for future researches and studies. This also aims not only to reach out to people in different walks of life to the rich and the poor, young and old ones, and to the next generations that are yet to come who are, and will be experiencing such kind of disease, but also to augment and enhance our life-long skills that our institution, DOSCST, has provided us through the quality education it proffers.

Scope and Limitation of the Study This paper only intends to study patient Lamarans condition, Nephrolithiasis, the anatomy associated with it, the pathophysiology of the disease process, its treatment and all the possible nursing interventions that can be implemented on patients suffering from the pain and discomfort of having urinary tract stones. Hence, this research paper, what we nursing students call case study, is only concerned and focused on Nephrolithiasis.

OBJECTIVES

Generally, this study aims to aid student nurses in gaining a new and deeper understanding about Nephrolithiasis and its management by presenting a comprehensive and substantial study conducted on Hussein E. Lamaran, last August 3, 2010 at General Ward, St. Camillus of Mati Foundation, Inc., Davao Oriental.

Specifically, this study aims to:

1. establish a good interpersonal and pleasant working relationship with the patient and his family so as to elicit trust and cooperation;
2. gather all relevant information of the case through retrieval of the patients

medical records, interview with the patient as well as with the significant others, and through further study from different sources in order to come up with a comprehensive analysis of the data acquired; 3. explain if the patient is able to achieve the tasks expected of him to accomplish in accordance to Erik Ericksons and Sigmund Freuds theories of growth and development, and determine if association between present disease state and developmental status is present;
4. provide the complete definition of the clients diagnosis and determine whether

they present disease state is hereditary or acquired;

5. determine what part of the human anatomy can be affected with the disease and

pathogenesis with respect to the risk factors that may arise from the case subject;

6. seek implication of the different laboratory examination the patient has undergone as varied through various points in the disease process and importance of the orders given by the physician; 7. . present the drugs administered to the client and explain why those drugs were given to him; 8. prospect level of recovery from the disease state related to the potentiating contributing factors present; 9. Make nursing care plans in carrying out nursing interventions to the complained and observed problems prioritized according to the urgency of relief of both the patient as well as his family; 10. discuss the personal management applicable to the patients condition upon his discharge; and 11. present the clients prognosis according to the duration and onset of illness, precipitating factors, compliance, age, environment and family support.

PATIENTS DATA

Name Lamaran, Hussein Entreno Age 36 y/o Birthday January 14, 1974 Gender Male Birthplace Banay-banay, Dvo. Or. Status Married

Ward SJOG Room No. PR 2 Religion Islam

Case Number 10-25346 Status Case Medicine Nationality Filipino

Spouse Name Jarelyn Lamaran Attending Physician Dr. Melina Maduay, MD Chief Complaint Hypogastric pain Final Diagnosis Nephrolithiasis

Address Purok Nigyan, Piso, Banay-banay, Dvo. Or. Date & Time Admitted Aug. 08, 2010 3:15 pm Admitting Diagnosis Nephrolithiasis Type of Admission From ER to ward per wheelchair

HEALTH HISTORY

Past Health History

Hussein, 36 y/o, was born on January 14, 1974 via NSVD (Norman Spontaneous Vaginal Delivery) at their house in Banay-banay, Davao Oriental through hilot. According to his mother, Hussein had completed his immunizations and had grown into a healthy boy. He was breastfed for a year and six months and was bottle-fed thereafter. He and his mother both claimed that he, Hussein, was fond of eating salty foods calcium rich foods. In addition to that, he also said that whenever he had headache and stomachache, or when he could feel pain, he took OTC drugs such as antacids and NSAIDs. When he was in college, he was diagnosed with Urinary Tract Infection and was not confined since he was given home meds such as antibiotics.

Present Health History

Two days prior to admission, Hussein had sudden onset of hypogastric pain. Alarmed by the persistent recurrence of such pain, he was admitted last August 08, 2010, 3:15pm at Saint Camillus Hospital in Mati. He was diagnosed with Nephrolithiasis under the service of Dr. Melinda Maduay, MD. He was given and IVF of PNSS 1L regulated at 120cc/hour and transported from ER to SJOG Geriatric ward via wheelchair

COMPLETE DIAGNOSIS

Nephrolithiasis

Nephrolithiasis or calculi are stone like formations. They may be found anywhere from the kidney to the urinary bladder and can vary in size from small grandular deposits like gravel or sand to bladder stones the size of an orange. (Burke, S. 1992 Human Anatomy & Physiology in Health & Diseases, 3rd ed. page 403) Nephrolithiasis is the process of forming a kidney stone, a stone in the kidney (or lower down in urinary tract. Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. Kidney stones occur in 1 in 20 people at some time in their life. The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in size from tiny to staghorn stones the size of renal pelvis itself. (http://www.medterms.com/script/main/art.asp?articlekey=6806) Nephrolithiasis is the formation of crystal aggregates in the urinary tract results in kidney stones, the clinical condition referred to as nephrolithiasis. Kidney stones might produce no symptoms or may be associated with one or several of the following: flank pain, gross or microscopic hematuria, obstruction of one or both kidneys, and urinary infections. (http://www.expertconsultbook.com/nephrolithiasis)

DEVELOPMENTAL DATA

Development is the improvement of the individuals skills and ability to function. Though usually interchanged with growth, they are totally different though. A persons growth is a quantitative change; it is measurable like height and weight. On the other hand, development is the individuals maturity in terms of capacity: and with it health workers could assess their clients well-being and personality. Our client, Hussein Lamaran, 36yr. old male, is a young adult (20 40 yrs.). Individuals in this level often start or are engaged in marital relationship and establish their personal lifestyle. Though development varies between individuals, as humans we have the same pattern; as evidenced by our gathered data. The patient has his own family, leisure activities, and lifestyle; the client spends his time on his business (copra) and also a good husband in his wife and also a good father in his children.

Developmental task theory Learning is basic in life and is a continuous process. It is in learning that we experience both success and failure. According to Robert Havighurst growth and development has a stages comprising in the entire life span. Within each stage, there is a central task known as developmental task. Developmental task arises at a certain period of the individuals life. Successful achievement would lead to complete well-being and sense of happiness but failure would cause grief and feeling of inferiority, they could be disappeared by the society and would find difficulty in achieving the coming task. With

Havighurst theory the client is in the early adulthood stage. We have here the task expected to be achieved by the person of these level and if he has met the tasks.

Developmental Task for Early Adulthood

1.) Selecting mate choosing a mate is an important to us. As human it is part of our

life and development. It is due to the fact that humans are creatures that are made to reproduce. Our client was able to meet the task since he was able to find a sexual partner and maintain a healthy sexual relationship with her.
2.) Learning to live with partner an intimate relationship is important between

couples. Our client is contented and happy in their relationship. Therefore he was able to meet the task.
3.) Starting a Family family is the basic unit of the society. Since the client has a

partner and children and raise them to good citizens in the future. We conclude that he was able to meet the task.
4.) Bearing Child a childs growth and development is a delicate process and

supportive parents are necessary to guide them throughout the process. As obtained from our interview, our client was able to achieve this. He was able to provide the need of his children, send them to school and discipline them properly.
5.) Managing a Home our client has partner which is held responsible to manage

their home. And also being the husband, he gives what his family need, especially when it comes to finances.

6.) Getting Started in One Occupation since our client is providing the needs of

his family and has a productive occupation, even though he wasnt able to finish his studies. He owns a Coprasan, and he was also a copra buyer. With these evidences, we could say that the client has achieved the task.

The client was able to achieve all the tasks of the young adulthood since he was able to meet most of the task that was expected in his level.

Erick Ericsons Psychosocial Development Psychosocial development refers to the development of personality. Personality is a complex concept and could be altered by simple events even when a person is still young. In Erick Ericsons theory he believes that personality develops throughout the entire lifespan and he divided the development process into and stages which arrives either good or bad outcome Stage Infancy Early childhood Late childhood School Age Adolescence Young Adulthood Adulthood Maturity Age Birth- 18 months 18 months- 3 years 3 5 years 6 12 years 12 18 years 18 25 years 26 65 years 65 death Crisis Trust vs. Mistrust Autonomy vs. Mistrust Initiative vs. Guilt Industry vs. Inferiority Identity vs. Role Confusion Intimacy vs. Isolation Generativity vs. Stagnation Integrity vs. Despair

The client is on the seventh stage of the development process and has arrived the crisis of generativity versus stagnation. On this stage, he is in the conflict between a creative, productive and concerned individual or self-indulging and self-concerned. We evaluated the client using the said characteristics to determine if he is completed, partially met or failed to accomplish his task.

Creativity and Productivity Creativity is the ability to produce an initiative whenever necessary and productivity shows the ideas of effectiveness. These characteristics are present in our client as evidence by the methods (coprasan and copra buyer) which he used to earn income and to support his family. This method are effective though he lack education, he was able to become good provider for her family.

Concern to Self and Other Self-concern is normal for an individual, but too much of it would lead to selfishness. Base on the data we have obtained, the client has satisfactory level of selfconcern. He was able to provide attention to his family. He was able to fulfill his responsibilities with his family and also in their business.

Self-Indulgence Indulgence is the failure to choose correctly between what is wanted and what is necessary. The client was still able to prioritize his family and also his business because it supports their financial need. In accordance to the theory of Erik Eriksons, we concluded that our patient Hussein is a generative individual. He was able to meet most of the task in his level.

PHYSICAL ASSESSMENT

A.

Intitial Assessment

Vital Signs BP= 120/90 mmhg Temperature= 36.9 C Pulse Rate= 71 bpm Respiratory rate= 21 cpm

General Survey Received on bed, awake, conscious and coherent with PNSS L 2 120 cc/hour, infusing well at left metacarpal vein. B. Cephalocaudal HEAD The clients head is symmetrical and no fracture observed with a smooth short black evenly distributed hair without flakes, lesions, masses, tenderness and head lice noted on scalp. Face is symmetrical, no pain and tenderness upon palpation. EYES Eyes are symmetrical with evenly distributed hair in the eyebrows and eyelashes. Eyelids can close properly and no difficulty. No discharges, lesions, redness, swelling noted on both eyes. Sclera appears white and conjunctiva appears pink in color. The client has no known deficits such as color blindness. EARS

Patient could hear well. No lesion, discharges, and signs of infection. No other abnormalities found. NOSE External nares are clear of any discharges. No deviation from normal appearance noted. MOUTH Pouted lips, no tooth decay ang gingivitis seen. NECK Free from any enlargement and tenderness upon palpation. CHEST No deformation on chest noted. There is no signs of any respiratory distress. No breath sounds noted upon auscultation. ABDOMEN Abdomen has hypogastric tenderness. GENETALIA Patient refuses for the exposure of his genital.

ANATOMY & PHYSIOLOGY The Kidney The kidneys are bean-shaped organs that sit in the back of the lower abdominal cavity on either side of the spinal cord. The organs are cushioned by perinephric fat, fatty tissue that surrounds the kidneys and adrenal glands to prevent damage and movement in the abdominal cavity.

Under normal conditions, humans are born with two kidneys, but it is possible to survive with only one as long as disease or other factors do not strain the organ.

Kidney Function The main function of the kidney is to maintain the fluid, electrolyte, and pH balance of the body by filtering ions, macromolecules, water, and nitrogenous wastes from the blood based on the bodys condition. Wastes filtered out of the blood drains from canals in the kidney into the bladder as urine. Blockage of the drainage system can cause the kidney to become congested, stretched, and potentially scarred. Functioning

kidneys are necessary to maintain life, and one measure of their function is the glomerular filtration rate. A loss of kidney function results in the need for dialysis, which is an artificial method of removing wastes from the blood by running the blood from the body, through an artificial kidney, and then back into the body. The major functions of the urinary system are performed by the kidneys, and play the following essential roles in controlling the composition and volume of body fluids. 1. Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of which are toxic, from the blood. Most waste products are metabolic by-products of cells and substances absorbed from the intestine. the skin, liver, lungs, and intestine eliminate some of these waste products, but they cannot compensate if the kidneys fail to function. 2. Regulation of blood volume and pressure. The kidneys play a major role in controlling the extracellular fluid volume in the body by producing either a large volume of dilute urine or small volume of concentrated urine. Consequently, blood volume and blood pressure are regulated by the kidneys. 3. Regulation of the concentration of solutes in the blood. The kidneys help regulate the concentration of the major molecules and ions such as glucose, sodium, potassium and calcium. 4. Regulation of extracellular fluid pH. The kidneys secrete variable amounts of hydrogen to help regulate extracellular fluid pH.

5. Regulation of red blood cell synthesis. The Kidneys secrete a hormone, erythropoietin, which regulates the synthesis of red blood cells in bone marrow. 6. Vitamin D synthesis. The kidneys play an important role in controlling blood levels of calcium by regulating the synthesis of vitamin D. Nephron is the basic structural and functional unit of the vertebrate kidney, with numerous such filtering units carrying out nearly all the functions of the kidney. The chief function of neprhons is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed, and excreting the rest as urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH. The nephrons' functions are vital to life. In human beings, there may be a million nephrons in each kidney. These are involved in intricate coordination with other systems to provide homeostasis for the body, remove wastes, and retain important nutrients. For example, in the presence of antidiuretic hormone (ADH or vasopressin), the ducts in the nephrons become permeable to water and facilitate its reabsorption, thus concentrating and reducing the volume of the urine. However, when the organism must eliminate excess water, such as after excess drinking, the production of ADH is decreased and the collecting tubule becomes less permeable to water, rendering urine dilute and abundant. Breakdown in this harmonious coordination can result in failure to decrease ADH production appropriately, leading to water retention and dangerous dilution of body

fluids, which in turn may cause severe neurological damage. Failure to produce ADH (or inability of the collecting ducts to respond to it) may cause excessive urination. Because of its importance in body fluid regulation, the nephron is a common target of drugs that treat high blood pressure and edema. These drugs, called diuretics, inhibit the ability of the nephron to retain water, thereby increasing the amount of urine produced.
[Glomerulus is red; Bowman's capsule is white.]

Each nephron is composed of an initial filtering component (the "renal corpuscle") and a tubule specialized for

reabsorption and secretion (the "renal tubule"). The renal corpuscle filters out large solutes from the blood, delivering water and small solutes to the renal tubule for modification.

Renal corpuscle Composed of a glomerulus and Bowman's capsule, the renal corpuscle (or Malpighian corpuscle) is the beginning of the nephron. It is the nephron's initial filtering component. The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. The glomerular blood pressure provides the driving force for water and solutes to be filtered out of the blood and into the space made by

Bowman's capsule. The remainder of the blood (only approximately 1/5 of all plasma passing through the kidney is filtered through the glomerular wall into Bowman's capsule) passes into the narrower efferent arteriole. It then moves into the vasa recta, which are collecting capillaries intertwined with the convoluted tubules through the interstitial space, in which the reabsorbed substances will also enter. This then combines with efferent venules from other nephrons into the renal vein, and rejoins the main bloodstream. The Bowman capsule, also called the glomerular capsule, surrounds the glomerulus. It is composed of a visceral inner layer formed by specialized cells called podocytes, and a parietal outer layer composed of a single layer of flat cells called simple squamous epithelium. Fluids from blood in the glomerulus are filtered through the visceral layer of podocytes, and the resulting glomerular filtrate is further processed along the nephron to form urine. Renal tubule The renal tubule is the portion of the nephron containing the tubular fluid filtered through the glomerulus. After passing through the renal tubule, the filtrate continues to the collecting duct system, which is not part of the nephron. The components of the renal tubule are:

Proximal tubule Loop of Henle

o o

Descending limb of loop of Henle Ascending limb of loop of Henle

Thin ascending limb of loop of Henle Thick ascending limb of loop of Henle

Distal convoluted tubule

The loop of Henle, also called the nephron loop, is a U-shaped tube that extends from the proximal tubule. It consists of a descending limb and ascending limb. Functions The nephron carries out nearly all of the kidney's functions. Most of these functions concern the reabsorption and secretion of various solutes such as ions (for example, sodium), carbohydrates (for example, glucose), and amino acids (such as glutamate). Properties of the cells that line the nephron change dramatically along its length; consequently, each segment of the nephron has highly specialized functions. The proximal tubule as a part of the nephron can be divided into an initial convoluted portion and a following straight (descending) portion (Boron and Boulpaep 2005). Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily glucose and amino acids). The loop of Henle, which is the U-shaped tube that extends from the proximal tubule, begins in the cortex, receiving filtrate from the proximal straight tubule, extends into the medulla as the descending limb, and then returns to the cortex as the ascending limb to empty into the distal convoluted tubule. The primary role of the loop of Henle is to concentrate the salt in the interstitium, the tissue surrounding the loop.

Considerable differences distinguish the descending and ascending limbs of the loop of Henle. The descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs. Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic filtrate is passed to the distal convoluted tubule in the renal cortex. The distal convoluted tubule has a different structure and function to that of the proximal convoluted tubule. Cells lining the tubule have numerous mitochondria to produce enough energy (ATP) for active transport to take place. Much of the ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the tubule also secretes hydrogen and ammonium to regulate pH.

After travelling the length of the distal convoluted tubule, only about 1 percent of water remains, and the remaining salt content is negligible.

PATHOPHYSIOLOGY

A. Symptomatology

Symptoms Abdominal Pain Dysuria

Remarks + +

Rationale Due to the presence of stones in the right kidney the patient experiences abdominal pain. When stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. Due to the abrasive action of the stones as urine passed. Fever did not manifest because there is no further infection.

Hematuria Fever

+ -

B. Etiology

Predisposing Factors

Factors Race

Remark Present

Rationale Urinary tract calculi are more common in Asians and whites than native American, Africans, and some native Mediterranean. Nephrolithiasis is more common to male than female (ratio of 3:1). Most urinary calculi develop in persons aged 20-49 years old.

Sex Age

Present Present

Precipitating Factors

Factors Lifestyle Diet

Remarks Actual Actual

Rationale Our patient is living in a sedentary lifestyle. He doesnt have a daily exercise and Hussein is always eating can goods, noodles, and since they are Islam they tend to eat protein rich food like fish and chicken. The surrounding of our patient was good and it is not congested.

Environment

C. Schematic Diagram

D. Narrative Pathophysiology

Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increased - referred to as super saturation which is dependent on the amount of the substance, ionic strength, and pH of the urine. Stones may be found anywhere from the kidney to the bladder and may vary in size from minute granular deposits, called sand or gravel, to bladder stones as large as an orange.

Stone formations not clearly understood, and there are a number of theories about their causes. One theory relates to the fluid volume status of the patient (stones tend to occur more often in dehydrated patients). Certain factors favor the formation of stones, including infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism. In addition, increased calcium concentrations in the blood and urine promote precipitation of calcium and formation of stones (about 75% of all renal stones are calcium-based). It is thought that high protein diet is associated with increased urinary excretion of calcium and uric acid, thereby causing a super saturation of these substances in the urine. Similarly, a high sodium intake has been shown in some studies to increase the amount of calcium in the urine.

LABORATORY RESULTS

Hematology Date ordered: 8/3/10 Parameter Hemoglobin Mass Concentration Segmentor Lymphocyte Result 153 0.55 0.20 Normal Values 140-160 /L 0.55-0.65% 0.6-5.1 Interpretation Normal Normal

Hematocrit Platelets Urinalysis Date ordered: 8/3/10 Parameter Color Appearance

0.46 265

0.42-0.52 140-440

Normal normal

Result Yellow Hazy

Normal Values Pale to Dark yellow Clear

Interpretation Normal not normal indicates the presence of lipids and

Specific Gravity

1.020

1.007-1.010

protein in the urine Above normal indicates that the kidney has the inability to concentrate and

Reaction (pH) Pus cells Erythrocytes Albumin

5.0 6-10 30-35 hpf (+)

4.6-8.0 1-2 hpf Negative(-) Negative(-)

dilute urine Normal Above normal indicates infection Not normal; indicative for hematuria Indicates hematuria.

Ultrasound Report Mild hydronephrosis, right kidney with a non-obstructing lithiasis in its inferior calyx Sonographically normal left kidney, urinary bladder and prostate gland

SUMMARY OF DOCTORS ORDER Date of Order Medical Ordered Rationale

8/03/10 3:15PM

Admit to room of choice Under Dr. Maduay

To provide immediate and proper comfort and care to the patient since the patient is complaining of hypogastric pain.

LSLF

To prevent hypertension and to decrease clients blood pressure.

VSq4 Start PNSS @ 120cc/hr

To monitor clients health status To support circulating volume and prevent dehydration of the body

Labs: CBC To discover abnormalities in a sample of a persons blood, such as the presence of alcohol, drugs, or microorganisms and to determine blood group. U/A Used to determine chemical and microbiological properties of urine and diagnose urinary tract disorders, kidney disorders, and other medical conditions that produce changes in the urine.

Medications: HNBB 1 tab q 8 Cefuroxime 750 mg slow IVTT q 8 ANST Increase OFI To prevent dehydration To avoid infections.

Refer unusualities to Attending Physician

So that physician will know current condition of the patient

Refer unusualities

To have an abrupt intervention of any abnormalities that might occur.

Schedule for 8/03/10 6PM USD(Ultrasound) of KUB tonight

To roughly evaluate the significant dispasity in the size, shape, and location of both kidneys, and detect abnormalities such as kidney stones, tumors and other obstructions.

Continue monitoring

To check and monitor patients current condition

IVFTF PNSS @ SR x 2 8/03/10 11:30PM cycles

To maintain fluid requirement of the body and prevent dehydration.

Refer to Davao City 8/04/10 8:00AM Nephron Surgeon

Admitting to Davao City Nephron Surgeon will help provide medical assistance for further observation and evaluation.

MGH

May go home as patient exhibits declination of signs and symptoms manifested.

Home Meds: Ofluxacin 2mg 1 tab BID

DRUG STUDY

Generic Name
Cefuroxime

Brand Name

Classification
Antibiotic

Action
Inhibits synthesis of bacterial cell wall, causing cell death.

Indication
Pharyngitis, tonsillitis caused by Streptococcus pyogenes. Otitis media caused by Streptoccocus pneumonia, S. pyogenes. Haemophilus influenza. Moraxella catarrhalis Lower respiratory infections

Contraindication
Contraindicated with allergy to cephalosporins or penicillin.

Nursing Responsibilities
1.History: Hepatic and renal impairment, lactation pregnancy. 2. Physical: Skin status, renal function tests, cultured of affected area, sensitivity tests. 3. Take full course of therapy even if you are feeling better.

caused by S. pneumoniae, Haemophilus parainfluenzae, H. influenza UTIs caused by Escherichea coli, Klebiella pneumonia Uncomplicated gonorrhea ( urethral and endocervical ) Skin and skin structure infections, including impetigo, caused by Stretococcus aureus, S. pyogenes 7. You may experience these side effects. Stomach upset or diarrhea. 8. Report severe diarrhea with blood, pus, or 4. this drug is specific for this infection and should not be used to self-treat problems. 5. Swallow tablets whole, do not crush them. 6. Take the drug with food.

 Treatment of early lyme disease.

mucus; rash; difficulty breathing, unusual tiredness, fatigue, unusual bleeding or bruising, unusual itching or irritation.

Generic Name

Brand Name

Classification

Action

Indication

Contraindication

Nursing Responsibilities

Hyosine-NButylbromide

Buscopan

Antispasmodics

Inhibits acetylcholine at receptor sites in autonomic nervous system, which controls secretions, free acids in stomach; blocks cential muscarinic receptors which decreases involuntary movements.

Acute GI, Biliary and genitourinary spasm, include biliary and renal colic,

Myasthemia gravis, megacolon, hypersensitivity.

1. Assess constipation. 2. Assess for urinary hesitancy, retention, palpate bladder if retention occurs. 3. Tell patient to

dysmenorrhea.

avoid hazardous activities requiring alertness; dizziness may occur. 4. Inform patient that the drug passes into the breast milk and decreases milk flow. 4. Adverse patient to avoid use of alcohol or other

CNS depressants while taking medication. 5. Explain that rinsing mouth, good oral hygiene, and sugarless gum or candy will help to counteract mouth dryness.

Generic Name
Potassium Citrate

Brand Name
Acalka

Classification
Antiurolithic

Action
The aim of the treatment is to

Indication
Treatment of patients with

Contraindication
Contraindicated to renal insuffieciency,

Nursing Responsibilities
The tablets must not be masticated or diluted.

restore the level of the urinary citrate and to increase the pH of urin to 6-7.

renal lithiasis and hypocitrauria, chronic formers of calcium oxalate, phosphate calculia.

respiratory or metabolic alkalosis, actice peptic ulcer, intestinal obstruction.

The active component of acalka is contained with a porous wax matrix.

Generic Name
Ofloxacin

Brand Name
Inoflox

Classification
Antibiotic

Action
Interferes with conversion of intermediate DNA fragments into high molecular weight DNA in bacteria.

Indication
Treatment of infections in urinary tract.

Contraindication
Hypersensitivity, tendonitis and rupture associated with quinolone use.

Nursing Responsibilities
1. Monitor allergic reaction of the patient. 2. Instruct patient not to take any medication during therapy unless approved by physician.

IVF

Date ordered

General Description

Indication

Clients reaction to treatment

PNSS

August 03, 2010

Isotonic fluid is used drips for patients who cant take fluids orally and have developed or are in danger of developing dehydration or hypovolemia.

Replacement and electrolytes.

Client showed no adverse reactions.

frequently in intravenous maintenance of fluid and

NURSING CARE PLAN Assessment Scientific Basis Planning Intervention Evaluation

Subjective: Nganong naa man bato akong kidney nga dili mn nako ginapugnan akong ihi? as verbalized by the patient. Objective: Patient asked questions about his condition. Patient was unfamiliar with the things that contribute to his condition like salty foods.
Patient requested for

list of contraindicated foods.

Knowledge deficit is a lack of cognitive information or psychomotor skills required recovery, maintenance, health promotion. Teaching may take place on a hospital, ambulatory care or hospital setting. The learner may be the patient, a family member a significant other or a caregiver related unrelated to the patient. Learning may involved any of the 3 domains cognitive domain, affective domain and psychomotor domain. In the case of this client the kidney stones in which he did not know up until he was diagnosed. Therefore, he doesnt

After 2 hours of nursing intervention patient will verbalize understanding of the disease process and potential complications.

Independent: Reviewed disease process and future expectations.

R: provides knowledge base from which patient can make informed choices.

Goal met. ahh cge nakasabot nako day nganong nay bato tungod day ni sa aqng ginakaon as verbalized by the patient.

Stressed importance of increased fluid intake.

R: flushes renal system, decreasing opportunity for urinary stasis and stone formation.

Encouraged patient to notice dry mouth and excessive dieresis / diaphoresis and to intake increase fluid intake whether or not feeling thirsty.
R: increased fluid losses/dehydration require

Analysis: Knowledge deficit r/t lack of information to present condition as evidenced by question

know much about his condition.

additional intake beyond usual daily needs.

Reference: Smeltzer,S.C,et. al; Textbook of medicalsurgical nursing(11th ed.), 2008 Lippincott William and Wilkins Publishing

Reviewed dietary regimen as individually appropriate.

R: diet depends on the type of stone. Understanding reason for restriction provides opportunity for the patient to make informed choices. Increase cooperation with regimen and may prevent recurrence.

Instructed patient with his diet - low purine diet.

R: reduces risk of calcium stone formation.

Instructed patient to have low ovalate diet.

R: reduces calcium oxalate stone formation.

 discussed meds regimen; avoidance of OTC drugs

R: drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation.

Assessment

Scientific Basis

Planning

Intervention

Evaluation

Subjective:

Calculi traumatized

Long term Objective:

Monitored and

Long term Objective:

-------------------

the walls of the urinary tract and Objective: irrigate the cellular 150 cc urine collected lining, causing pain for 8hrs with a yellow as violent contraction of the to brownish colored ureter develops to urine pass the stone along. But the urethral no crystals or blood spasm may just as observed. easily hold a stone in Patient goes to comfort place. If a stone room once or twice per totally or partially shift obstructs the passage urine beyond its Analysis: location, pressure increases in the area Risk for infection r/t to stasis of urine 2 above the stone. The pressure contributes nephrolithiasis. to the pain and the urinary stasis promotes secondary infections. The retained urine distended the renal pelvis. Eventually

After 2 -3 days of nursing intervention: The patient will be able to understand and identify interventions to prevent and reduce risk for infection; The patient will be able to emphasize consulting with the physician before self/administering any over the counter medication; and Over the counter medication can contribute to the illness which may result for further complication to the condition.

recorded VS especially the temperature.

R: establishes a baseline for comparison. Changes to baseline data may indicate t he presence of infection. Fever usually is the first and only sign of infection.

Goal met. The patient was able to take the following measures; a. follow appropriate given instructions; b. demonstrate understanding to given measures; and c. apply given instructions in everyday routine.

Monitored intake and output.

R: diuretic therapy may result in sudden excessive fluid loss even though edema remains.

Explored causative factors, review laboratory data and nonverbal cues.

R: knowledge of causative factors influences plan of intervention.

Maintained hydration

there may be compression of the glomeruli and tiny arterioles that supply to the kidney which result permanent damage.

and voiding schedule.

R: to prevent bladder distention and urinary stasis that can contribute to the multiplication of pathogens.

Reference: Smeltzer,S.C,et. al; Textbook of medical-surgical nursing(11th ed.), 2008 Lippincott William and Wilkins Publishing

Provided regular urinary catheter and perineal care.

R: This reduces risk for infection.

Maintained sterile technique for all invasive procedures such as IV and urinary catheter.
R: This reduces risk for infection.

Encouraged to increase oral fluid intake to at least 3.5 4 L/day.

R: To maintain normal hydration and prevent urinary stasis.

Encouraged to verbalize any feelings and significant changes to the condition.

R: For immediate access to nursing intervention.

Emphasized necessity if taking anti-viral and antibiotics as directed.

R: Premature discontinuation of treatment when client begins to feel well result in return of infection and potentiate drug resistant strains.

Assessment

Scientific Basis

Planning

Intervention

Evaluation

Subjective: Sakit akong tiyan as verbalized by the patient Objective:

Restlessness

facial mask of pain pain scale of 0-10; 8/10 VS Bp= 120/90 mmHg T- 36.9 C P= 71 bpm R= 21 cpm

When stones block the flow of urine, obstruction develop, producing an increase hydrostatic pressure and distending renal pelvis and proximal ureter and patient has a desire to void but little urine is passed.

Within 8 hour span of care patient will:

report pain relieved or

Independent: Established rapport to patient as well as his watcher.

R: To gain their cooperation and trust

controlled; and
appear relax and be able to

sleep or rest appropriately condition.

Goal partially met as evidence by verbalization sakitsakit gihapon gamay gang, pero dili jud parehos ganiha nga sakit kayo Pain scale 5/10

Provided comfort measures like back rub and restful environment.

R: This promotes relaxation, reduces muscle tension and enhances coping.

Reference: Smeltzer,S.C,et. al; Textbook of medical-surgical nursing(11th ed.), 2008 Lippincott William and Wilkins Publishing

Applied warm compress to back.

R: This relieves muscle tension and may reduce reflex spasm.

Analysis: Acute Pain related to the obstruction and abrasion of the urinary tract secondary to

Encouraged use of focus breathing and diversional activities such as watching tv and

Nephrolithiasis

reading magazine.
R: This redirects attention and aids in muscle relaxation.

Encouraged patient frequent ambulation as indicated and increase OFI at least 3-4 liters per day.
R: Renal colic be worst in supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.

Encouraged to

verbalize the increase and persistent abdominal pain.

R: Complete obstruction

of ureter can cause perforation and extravasation of urine into perirenal space.

Dependent: HNBB given as ordered NOD aware.

DISCHARGE PLAN

Medications Instruct patient to continue taking his medication Explain to the patient the purpose and possible effects of the medication Instruct patients family to remind the patient the perfect timing in taking his medication also include the right route and the right dose. Reassure the family that many side effects of the medication will resolve when the drug is stopped.

Environment Strictly observe a clean place living for the patient and give importance on what a dirty environment effects on the patient. Provide an efficient living place for the patient make his life an easy way to live, place where all his need could be provided.

Treatment Be more understanding and sensitive towards the needs and the acts of the patient. Patient must be provided with his basic needs for everyday living, make everything simple for him.

Diet Patient should refrain from eating salty and fatty foods as well as foods that are rich in calcium and protein.

Patient should eat healthy food such as vegetables and fruits.

Outpatient Referral Instruct the patient to follow the doctors order as to when to consult for the follow-up check-up. Instruct the significant others that if the patients condition does not improve or worsen, an immediate return to the emergency department must be warranted. Discuss with the family when and how to call the physician. Give the significant others a list of name and phone numbers of how to get medical assistance at any hour of day and night.

PROGNOSIS Category Poor Fair Good Justifications

The clients illness occurred abruptly, but two days prior to admission the client complained a sudden pain in his abdomen. It wasnt notice until he was admitted. The patient is used to eat canned goods and fund of drinking soft drinks.

1.) Duration of Illness 2.) Onset of Illness

3.) Precipitating Factors 4.) Willingness to take medicine or compliance to treatment regimen

The clients family was able to provide the medicines needed by the patient. He completed his medication until discharge. Ages at risk for this kind of disease ranges from 22-49y/o, and our patient belongs to this age range. The hospital was a suitable environment for rendering health care to the patient. The facilities were rendering care to the patients health needs. Patients family and relatives were very supportive. They were at his side throughout his hospitalization.

5.) Age

6.) Environment

7.) Family support 2/7 * 100 = 28.5% 2/7 * 100 = 28.5%

3/7 * 100 = 42.8%

Calculations

42.8% GOOD PROGNOSIS

Based on what the table above shows, there is a good prognosis since the choice good outweighed the others.

DEFINITION OF TERMS

Analgesic is a drug that relieves pain. Diuresis means increased urine secretion in the kidney. Diuretics are drugs that increase the volume of the urine production by promoting the

excretion of salts and water from the kidney. Dysuria means difficult or painful urination. This is usually associated with urgency and

frequency of urination if due to urethritis or cystitis. Extravasation is the leakage and spread of blood and fluids from vessels into

surrounding tissues KUB x-ray is an abdominal plain x-ray film that longer than normal to enable it to

include the kidneys, ureters, and the entire bladder. Lithiasis is the formation of stones in an internal organ such as gall bladder, urinary

system, pancreas and appendix. Nephron is the active unit of excretion in the kidney NSVD (Normal Spontaneous Vaginal Delivery) means delivering baby through vaginal

canal. Pyuria is the presence of pus in the urine, making it cloudy. This is a sign of bacterial

infection in the urinary tract. Sodium (Na) is a mineral element and an important constituent of the human body.

Sodium controls the volume of intracellular fluid in the body and maintains the acid-base imbalance. Stasis is the cessation or stagnation of flow.

CONCLUSION In this case study, the objectives that were formulated were met. The group was able to learn what Nephrolithiasis is as to how and why such condition occurs. Similarly, we were able to practice our nursing skills and apply the theories and concepts that we have learned during our lecture days. In addition to this, dealing with a client with Nephrolithiasis gave us the opportunity to review the different body systems involved, and the possible manifestations that would appear on a client with this kind of disease process. Also, the group was able to familiarize some various tests and diagnosis associated with such kind of condition. As student nurses, the group was able to apply the proper nursing interventions and assessment. With regards to the client-centered objectives, the client was able to acquire knowledge about the current condition and carry out actions independently.

BIBLIOGRAPHY
Books:

Doenges, e. (2008). Nurses Pocket Guidediagnosis, prioritize interventions and rationales, 11th ed. Philadelphia, PennsylvaniaF.A Davis Company. Doenges, e. (2005). Nursing Care PlanGuidelines for individualizing client care across the lifespan, 7th ed. Philadelphia, PennsylvaniaF.A Davis Company. Johnson, J. (2008). Handbook for Brunner and Suddath's Textbook for medicalsurgical, 11th ed. Lippincott William and Wilkins Publishing. Karch, A. (2009). Lippincott's Nursing Drug Guide. Lippincott William and Wilkins Publishing. Kozier, e. (2009). Fundamentals of Nursing Pearson Education Inc. 7th ed. Lippincott William and Wilkins Publishing. Porth, C. (2005). Pathophysiology 7th ed. Lippincott William and Wilkins Publishing. Smeltzer, S. e. (2008). Textbook for medical-surgical nursing 11th ed. Lippincott William and Wilkins Publishing. The Bantam Medical Dictionary 6th ed. (2009). New YorkBantam Dell A Division Of Random House Inc.

Non-books: http://anatomyphysiology.suite101.com/article.cfm/renal_anatomy_&_physiology http://www.medterms.com/script/main/art.asp?articlekey=6806 http://kidney.niddk.nih.gov/kudisease/pubs/kustats http://www.doh.gov.ph/kp/statistics/lading mortality as of 2008